The Community Hospital of the Monterey Peninsula (CHOMP) is a 225-bed hospital in Monterey County, California, that sees about 56,000 patients in its emergency department every year.
Many of these visits are from patients with high utilization patterns, defined as four or more visits a year; some patients have more than 20 visits per year. Together, these patients account for almost 30% of all emergency department visits. And, more importantly, these patients often have complex care needs, including behavioral health issues or substance use disorder.
“The opioid crisis continues to be a huge issue across the country, but in Monterey County, we’ve been seeing success in slowing the growth of the epidemic by working together with other medical providers throughout the area,” said Dr. Reb Close, an emergency physician at CHOMP. “CHOMP has combined local opioid prescribing guidelines with the state prescription drug monitoring program (PDMP) and care coordination to improve substance use disorder and put a stop to opioid misuse.”
"Having all this information recorded and delivered in a notification keeps the process manageable by ensuring we do not have to stop and manually look up these guidelines for each patient."
Dr. Reb Close, Community Hospital of the Monterey Peninsula
Opiate injections and prescriptions are treatments that can help patients with chronic pain feel better faster. Because they are quick, physicians can continue to see more patients and keep their busy emergency departments running smoothly.
However, patients with substance use disorder often travel between points of care with similar complaints to receive the medications they are seeking. Without transparency into patient medical and prescription histories, it is almost impossible for providers to determine which patients have legitimate pain issues and which are just looking for their next prescription.
CHOMP knew it needed a better way to understand the actual medical needs and prior interventions for any particular patient so it could determine the best emergency department intervention it could offer. The hospital also needed to connect patients with continued long-term care support that it could not provide in the emergency department.
“So, a team of physicians began working together to develop the Monterey County Prescribe Safe Initiative, a multi-agency collaborative effort to reduce prescription medication misuse,” Close explained. “The initiative brought together local physicians, social work experts, law enforcement, pharmacies, drug recovery centers, and hospital leadership to develop pain management guidelines and protocols that could be implemented across Monterey County.”
To facilitate better care collaboration and interventions for emergency department patients across the community, CHOMP turned to health IT vendor Collective Medical. The Collective Medical platform connects CHOMP’s emergency department with other emergency departments across both the county and the country to send relevant, real-time patient notifications to physicians at the point of care.
This collaborative tool is integrated with California’s PDMP, so it delivers key information about medication prescription histories to physicians as soon as a patient presents to the emergency department.
There is a variety of care coordination health IT vendors on the market today, including Ensocare, eQHealth, Greenway Health, GSI Health, Imprivata, Optum, pMD and VitalHealth Software.
MEETING THE CHALLENGE
Because the PDMP is integrated with the notifications, CHOMP is able to see when a patient being treated recently received controlled medications from another provider, giving CHOMP invaluable insight into possible substance misuse and medication interactions.
With a more complete picture of the patient, physicians can understand what the patient actually needs – be it a connection to their primary care provider, a referral to a rehabilitation facility or alternative treatments for pain management.
“In addition to using this care collaboration tool, a collaborative, multi-disciplinary team meets regularly to discuss the treatment and progress of individual patients with high emergency department utilization or controlled medication use,” Close explained. “This task force includes a multi-disciplinary team of physicians, clinical nurse specialists, chemical dependency nurses, crisis intervention teams, social workers, psychiatrists and other behavioral health staff, and outpatient services.”
In collaboration with primary care providers, the team was able to develop and refine patient care guidelines, then share those guidelines with the patient and the rest of their care team. This helps establish care expectations, including who will be prescribing the patient controlled medications, and define appropriate settings to receive care for various conditions.
Care guidelines were made easily accessible via real-time delivery at the point of care, saving CHOMP time by presenting key information about medical and prescription histories without having to log into the care guideline section of the hospital’s EHR or to the PDMP.
While opioid misuse continues to be a big problem in many different parts of the country, CHOMP and other providers in Monterey County have been seeing the benefits of care collaboration efforts for patient care.
The combination of the Monterey Prescribe Safe Initiative and care collaboration produced the following results for Monterey County:
- A 32% reduction in opioid deaths;
- A 59% reduction in emergency department visits;
- A 47% reduction in variable cost avoidance in recurrent emergency department visitors under care management;
- More than a 50% decrease in the number of narcotic pills prescribed at local primary care clinics.
“And because of our efforts to reduce opioid use, we’re turning to non-opiate methods to treat pain, getting new treatment options and medications available for use in our hospitals, and working with insurance companies to improve coverage of new non-opiate therapies,” Close said.
For example, over a two-year period (2014-2016), the use of topical lidocaine patches for pain increased by 320%, the use of non-steroidal anti-inflammatories like ibuprofen increased by 150%, and two new non-opioid intravenous medications were added to the list of medications for use in the emergency department to treat pain.
CHOMP also has added virtual reality, procedural interventions, physical therapy and TENS interventions for pain treatment in emergency department patients.
ADVICE FOR OTHERS
“The more information you know about a patient’s prescription and medical history, the better care you can provide for them,” Close advised. “By pooling our resources from PDMP information and from care guidelines, we can see what’s really happening with a patient and determine what we can do to best help them. Having all this information recorded and delivered in a notification keeps the process manageable by ensuring we do not have to stop and manually look up these guidelines for each patient.”
A patient never plans on having complex pain and medication issues, and they do not plan on becoming dependent on or addicted to medications.
“When helping these people, it is so important to take an empathetic approach, really listen to their complaints, and dig into what is happening,” she said. “Prescribe Safe is meant to help providers do just that. By practicing informed, intentional treatments, we can help these patients not only find relief from their pain, but ultimately provide relief from and hope for dependency and addiction, too.”